1578063772 NPI number — MISS KIASHA SHIREE BAGGETT

Table of content: MISS KIASHA SHIREE BAGGETT (NPI 1578063772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578063772 NPI number — MISS KIASHA SHIREE BAGGETT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAGGETT
Provider First Name:
KIASHA
Provider Middle Name:
SHIREE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578063772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3925 N. MARTIN LUTHER KING BLVD.
Provider Second Line Business Mailing Address:
STE 211
Provider Business Mailing Address City Name:
NORTH LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-488-2284
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3925 N. MARTIN LUTHER KING BLVD.
Provider Second Line Business Practice Location Address:
STE 211
Provider Business Practice Location Address City Name:
NORTH LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-488-2284
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/15/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1831602291 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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